Japanese Journal of Clinical Oncology 31:341-345 (2001)
© 2001 Foundation for Promotion of Cancer Research
Isolated Splenic Metastasis of Sigmoid Colon Cancer: a Case Report
Department of Surgery, Koshigaya Hospital, Dokkyo University School of Medicine, Saitama, Japan
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
|---|
We report the case of a 62-year-old man who developed isolated splenic metastasis of sigmoid colon cancer. The patient underwent left hemicolectomy for Dukes C sigmoid colon cancer in February 1997. In March 1999, an abdominal CT scan revealed a tumor 3 cm in size at the inferior pole of the spleen. The tumor was hyperechoic on ultrasonography. The serum carcinoembryonic antigen level was normal. Since no other site of recurrence was identified, a splenectomy was performed with a curative intent. At laparotomy, neither hepatic metastasis, peritoneal dissemination, lymph node metastasis nor local recurrence was detected. Histological findings of the splenic tumor were compatible with metastasis of the previously resected sigmoid colon adenocarcinoma. The patient has been disease-free for 19 postoperative months. Immunohistochemical staining for urokinase-type plasminogen activator was positive in primary sigmoid colon cancer and splenic metastasis, but negative in lymph node metastasis; results that possibly reflect the difference in progenitor cells between splenic metastasis and lymph node metastasis or the difference in the microenvironment of cancer cells between the spleen and lymph nodes. Based on the present case, we recommend that clinicians pay close attention to the spleen for the early diagnosis of isolated splenic metastasis when routinely evaluating abdominal CT scans and abdominal ultrasonography following curative resection of primary colorectal cancer.
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
|---|
Splenic metastasis of colorectal carcinoma is rare and usually a sign of extensive disease (1). In this paper, we report a case of isolated splenic metastasis of sigmoid colon cancer that was successfully treated by splenectomy. Immunohistochemical staining for urokinase-type plasminogen activator (u-PA) in the primary lesion, lymph node metastasis and splenic metastasis revealed a difference in uPA expression between the lymph node metastasis and splenic metastasis. We discuss here the relevance of our findings to clinical practice and also review cases of isolated splenic metastasis of colorectal cancer reported in the Japanese and English-language literature.
|
CASE REPORT |
|---|
|
TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
|---|
An asymptomatic 62-year-old man was found to have a single low-density mass in the spleen by abdominal computed tomography (CT) scan in March 1999 (Fig. 1). He had previously undergone left hemicolectomy for a well-differentiated adenocarcinoma of the sigmoid colon in February 1997. The tumor invaded up to the subserosal layer (T3) with moderate lymphatic invasion and mild venous invasion. Three of nine excised lymph nodes were positive for metastasis (N2). No distant metastasis was found (M0) at the time of surgery. The patient was regularly followed up, having a physical examination every month, an abdominal CT scan and chest X-ray at 6-monthly intervals and a blood test including the measurement of serum carcinoembryonic antigen (CEA) level at 3-monthly intervals.
|
Upon follow-up, the tumor in the spleen was 3 cm in size and located at the inferior pole. The tumor was hyperechoic on abdominal ultrasonography. The serum CEA level continued to be within the normal range. A chest X-ray excluded pulmonary metastasis. CT and ultrasonography detected neither liver metastasis nor peritoneal dissemination. In May 1999, splenectomy was performed under the working diagnosis of splenic tumor. At laparotomy, no recurrence was identified except for a nodular mass 3 cm in size in the inferior pole of the spleen. Invasion to the surrounding organs or lymphadenopathy was absent.
Macroscopically, the tumor was solitary, homogeneous, yellowish white, clearly demarcated by a thin capsule and elastic firm in consistency (Fig. 2). Microscopically, the tumor was a well-differentiated adenocarcinoma (Fig. 3A), consistent with metastasis from the previously resected sigmoid colon cancer (Fig. 3B).
|
|
The postoperative course was uneventful. The patient was discharged on the seventeenth postoperative day. The patient remains asymptomatic as of January 2001 and no follow-up findings suggest recurrence.
We performed immunohistochemical staining for u-PA on the primary sigmoid cancer, the metastatic lesions to the lymph nodes and spleen (Fig. 4). The primary lesion and splenic metastasis were positive for u-PA, whereas the lymph node metastases were negative.
|
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
|---|
It is generally accepted that splenic metastasis of colorectal cancer is uncommon and usually occurs in association with other extensive metastases (1). Therefore, curatively resectable isolated splenic metastasis is rare. Of 504 patients who underwent curative resection of colorectal cancer at our institution between June 1984 and December 1996, the patient described here was the only one to undergo resection of splenic metastasis. Moreover, we located only 20 reported cases of isolated splenic metastasis of colorectal cancer in the Japanese literature (Table 1) and a mere eight in the English-language literature (Table 2).
|
|
Berge (1) reported the incidence of splenic metastasis as 7.1% in 7165 autopsy cases with various cancers, which is in stark contrast to that of 52% for liver metastasis. Although he reported the incidence of splenic metastasis of colorectal carcinoma as 4.4%, he made no mention of the incidence of isolated splenic metastasis.
Several hypotheses have attempted to explain the low incidence of splenic metastasis. It should be difficult for colorectal cancer cells to reach the spleen through the portal venous system in which the blood flow is usually from the spleen to the liver. Even if cancer cells did gain access to the spleen, formation of a metastatic nest in the spleen may be inhibited by the reticuloendothelial system (27) or the rhythmic contraction of the spleen may squeeze out the tumor embolus to prevent it from lodging there (28). The absence of afferent lymphatics to the spleen, phagocytic activity of splenic cells and humoral anticancer substances in the spleen are considered to be other reasons for the low incidence of splenic metastasis (1,29).
Both vascular and lymphatic routes have been proposed as the means of transmission for splenic metastasis of colorectal cancer (1,29,30). However, the majority of authors favor the former rather than the latter route, because the metastasis tends to be limited within the splenic parenchyma, with the lymph node at the splenic hilus negative for metastasis (4,10–13,15,16,18,19). Similar findings were evident in the patient described here. Although 19 of the 28 reported cases involved primary lesions with lymph node metastasis (Dukes C), this may simply reflect the fact that splenic metastasis is more frequent in more advanced tumors or that cancer cells entering the circulatory system from the mesenteric lymphatics via the venous angle form a metastatic nest in the spleen.
Immunohistochemical staining for u-PA demonstrated that both the primary lesion and splenic metastasis expressed u-PA, whereas the lymph node metastasis did not. Colorectal cancer which expresses u-PA reportedly develops hematogenous metastasis more frequently (31,32), through the enhancement of angiogenesis surrounding the tumor (32). The difference in u-PA expression between the splenic metastasis and lymph node metastasis in the present case may simply reflect the difference in progenitor cells. However, the microenvironment for cancer cells may differ between the lymph nodes and spleen, resulting in the difference in u-PA expression between the respective sites of metastasis. In any case, a larger number of cases with splenic metastasis should be studied using techniques of molecular biology and immunohistochemistry in order to clarify the mechanism of splenic metastasis.
In the reported cases, only six of the 28 patients were symptomatic at the time of isolated splenic metastasis diagnosis: epigastralgia in three patients (9,11,15) and general malaise (4), weight loss (21) and hematuria (17) in one each. Moreover, the symptoms were thought to be unrelated to the presence of splenic metastasis in three symptomatic patients, since the metastasis was small (<5 cm in diameter) (11,15,17). In 21 patients, the splenic metastasis was detected by elevated tumor marker levels, particularly carcinoembryonic antigen levels. Our patient was the only one who was asymptomatic and had normal serum tumor marker levels. Careful examination of the abdominal CT scan made early diagnosis of isolated splenic metastasis possible in our patient.
Twenty-seven of the 28 reported cases underwent curative splenectomy. The 1-year survival rate and median survival after treatment of splenic metastasis were calculated from the aforementioned reports as 86.6% and 66 months, respectively. Therefore, prognosis of isolated splenic metastasis after splenectomy appears somewhat optimistic despite the fact that splenic metastasis is one form of distant metastasis. Even for multiple splenic metastasis, splenectomy can be a potentially curative procedure. We therefore recommend that clinicians pay close attention to the spleen for the early diagnosis of isolated splenic metastasis when routinely evaluating abdominal CT scans and abdominal ultrasonography following curative resection of primary colorectal cancer.
|
FOOTNOTES |
|---|
+ For reprints and all correspondence: Masatoshi Oya, Department of Surgery, Koshigaya Hospital, Dokkyo University School of Medicine, 2–1 Minami-Koshigaya 50-chome, Koshigaya, Saitama 343-0845, Japan. E-mail: m-oya@dokkyomed.ac.jp
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONREFERENCES |
|---|
1 Berge T. Splenic metastases. Acta Pathol Microbiol Scand A 1974;82:499–506.[Medline]
2 Itakura Y, Sato M, Yashita T, Nakagawa S, Tanaka I, You K. A case of isolated splenic metastasis from colon cancer. Nippon Shokaki Geka Gakkai Zasshi 1987;20:625 (in Japanese).
3 Yamamoto T, Nishimoto K, Kanaya T, Ukai T. Two cases of splenic metastasis. Tottori Igaku Zasshi 1988;15:313 (in Japanese).
4 Fujita M, Seitoh D, Nakachi H, Moriya H, Ochiai K, Ozawa M, et al. Solitary splenic metastasis of cancer. Hakodate Igaku Zasshi 1990;14:54 (in Japanese).
5 Hiraoka T, Watanabe Y, Morikawa S, Goto S, Seko A, Amano K, et al. A case of splenic metastasis of colon cancer. Nippon Shokakibyo Gakkai Zasshi 1991;88:921 (in Japanese).
6 Obayashi Y, Morishita A, Asakawa T, Imano M, Tominaga K, Tanaka M, et al. A case of splenic metastasis of colon cancer. Nippon Shokaki Geka Gakkai Zasshi 1992;53:232 (in Japanese).
7 Horie M, Yanagi H, Noda M, Souji Y, Sakaue Y, Tachibana M, et al. A case of solitary splenic metastasis of colon cancer. Nippon Shokaki Geka Gakkai Zasshi 1992;53:232 (in Japanese).
8 Watanabe T, Sato H, Hattori K, Kojima M, Tokuda M, Matsushita K. Solitary splenic metastasis from carcinoma of colon: a case report. Nippon Rinsho Geka Gakkai Zasshi 1992;47:1245–8 (in Japanese).
9 Ogasawara T, Sekikawa T, Kawano K, Matsumoto Y. A case of metastatic splenic tumor treated with intra-arterial immunochemotherapy to induce endogenous LAK cell. Gan To Kagaku Ryoho 1993;20:1446–9 (in Japanese).[Medline]
10 Mizobuchi N, Tsuchiya M, Kanno T, Suzuki M, Kajiwara N. A case report of resected solitary splenic metastasis from rectal cancer. Nippon Rinsho Geka Gakkai Zasshi 1994;55:1555–9 (in Japanese).
11 Fujita K, Ishii S, Matsumoto K, Kobayashi K, Douwaki M, Nakagawa M, et al. A case of cecum cancer metastasizing to the spleen after right hemicolectomy. Nippon Rinsho Geka Gakkai Zasshi 1995;56:1431–5 (in Japanese).
12 Yamamura H, Nakamoto A, Aragaki K, Nakama T, Kinjou M, Sunakawa R, et al. A case of solitary splenic metastasis of colon cancer. Okinawa Igakkai Zasshi 1995;31:47–8 (in Japanese).
13 Endo S, Tsutsui M. Two cases of splenic metastasis resected from colorectal carcinoma. Nippon Daicho-Komonbyo Gakkai Zasshi 1995;48:617–22 (in Japanese).
14 Sawai T, Nakagoshi R, Tagawa Y, Sasano O, Yamaguchi H, Yasube R, et al. A case of solitary splenic metastasis from colon cancer. Nippon Geka Gakkai Zasshi 1996;97:1109–11 (in Japanese).[Medline]
15 Sekine Y, Okahara H, Mizobuchi N, Nagahama T, Sakakibara N. A case of cecum cancer metastasizing to the spleen after right hemicolectomy. Nippon Rinsho Geka Gakkai Zasshi 1996;57:1416–20 (in Japanese).
16 Fuku A, Yasuda Y, Sakaguchi S, Murakami S, Fuku K. A case of cecum cancer metastasizing to the spleen after right hemicolectomy. Nippon Shokakibyo Gakkai Zasshi 1997;94:33–7 (in Japanese).[Medline]
17 Kawahara S, Hirai K, Aoki T, Kuroda H, Suzuki T, Takeuchi K. A case of metachronous solitary splenic metastasis from sigmoid colon cancer. Nippon Rinsho Geka Gakkai Zasshi 1999;60:2171–3 (in Japanese).
18 Izumo A, Eguchi T, Kimura H, Hirota I, Kinjou M, Kimura S. Resected solitary splenic metastasis 2 years after early colonic carcinoma in one adult. Nippon Rinsho Geka Gakkai Zasshi 1999;60:2970–5 (in Japanese).
19 Watabe K, Yamazaki Y, Suda T, Mochizuki Y, Makino T, Okada K. Two cases of solitary splenic metastasis from colonic cancer. Nippon Rinsho Geka Gakkai Zasshi 1999;60:795–801 (in Japanese).
20 Dunbar WH, Bearhs OH, Morlock CG. Solitary splenic metastasis incidental to rectal carcinoma. Mayo Clin Proc 1969;44:40–5.[Medline]
21 Waller RM, Fajman WA. An unusual cause of an isolated, focal splenic defect demonstrated by liver-spleen scintigraphy. Clin Nucl Med 1982;7:5–6.[Medline]
22 Slavin JD Jr, Matthews J, Spencer RP. Splenectomy for splenic metastasis from carcinoma of the colon. Clin Nucl Med 1986;11:491–2.[Medline]
23 Thomas SM, Fitzgerald JB, Pollock RE, Evans DB. Isolated splenic metastasis from colon carcinoma. Eur J Surg Oncol 1993;19:485–90.[Medline]
24 Mariprize KS, Berry AR. Solitary splenic metastasis from colorectal carcinoma. Br J Surg 1997;84:70.[Medline]
25 Induhara R, Vogt D, Levin HS, Church J. Isolated splenic metastasis from colon cancer. South Med J 1997;90:633–6.[Medline]
26 Weathers B, Modesto L, Gordon D. Isolated splenic metastasis from colorectal carcinoma. Dis Colon Rectum 1999;42:1345–8.[Medline]
27 Miller NJ, Milton GW. An experimental comparison between tumor growth in the spleen and liver. J Pathol Bacteriol 1965;90:515–21.[Medline]
28 Kettle EH. Carcinomatous metastases in the spleen. J Pathol Bacteriol 1912;17:40–6.
29 Warren S, Davis AH. Studies on tumor metastasis. The metastasis of carcinoma to the spleen. Am J Cancer 1934;21:517–33.
30 Marymont JH, Gross S. Patterns of metastatic cancer in the spleen. Am J Clin Pathol 1963;40:58–66.
31 Mulcahy HE, Duffy MJ, McCarthy P, Parfrey NA, O’Donoghue DP, et al. Urokinase-type plasminogen activator and outcome in Dukes’ B colorectal cancer. Lancet 1994;344:583–4.[Web of Science][Medline]
32 Nakata S, Fujimori M, Shingu K, Kajikawa S, Adachi W, Matsumoto I, et al. Involvement of vascular endothelial growth factor and urokinase-type plasminogen activator receptor in microvessel invasion in human colorectal cancers. Int J Cancer 1998;17:179–86.
Received November 7, 2000; accepted March 14, 2001.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||